New research fuels debate over merits of common medical procedure

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For years, the question of whether new parents would circumcise their baby boys was generally a nonissue. Whatever the tradition was in their families, especially whether the baby's father was circumcised, usually decided the matter.

However, in the last several years — and particularly in recent months with the release of a few widely reported studies siding with circumcision — the topic increasingly has been subject for heated debate.

The opinions of friends and Berkeley, Calif., neighbors Judith Barish and Denise Leto epitomize the controversy.

Leto, a travel writer and mother of two sons ages 3 and 6, did not circumcise. “For us the decision was easy. Why would we change our children’s perfect bodies for so little? To me, the medical arguments have never made much sense.” What did make sense was her midwife’s bumper sticker: "100 percent of babies oppose circumcision."

Barish, a stay-at-home mother of an 8-year-old daughter and two boys ages 3 and 6, decided on circumcision. Although she says the medical reasons at the time were not altogether compelling, the decision was made for other reasons. “Our children are half Jewish. We debated the issue and really looked into it," she says. "The medical benefits versus the risk seemed like a wash. But ultimately we decided to circumcise as one small concession to religion and culture.”

Procedure's popularity declining
The United States leads the way in the number of babies circumcised each year. Estimates vary widely, ranging from 50 percent to more than 90 percent of newborn boys circumcised, depending on the region of the country (federal data from 1999 showed hospital circumcision rates of 81 percent in the Midwest, 66 percent in the Northeast, 64 percent in the South and 37 percent in the West) and religion (the Jewish and Muslim faiths traditionally call for circumcision). In Europe, Asia and Latin America, baby boys are not routinely circumcised, and the circumcision rates here have been dropping steadily over recent years.

“Parents across the country are rethinking circumcision and many, many are deciding against it,” says Dr. Mark Reiss, a retired physician in San Francisco, and the executive vice president of Doctors Opposing Circumcision.

The American Academy of Pediatrics has maintained a somewhat neutral policy, saying that while circumcision has some health benefits associated with it, along with surgical risks such as bleeding and infection, the procedure is not medically essential. However, recent studies have prompted the group to review its policy on circumcision, with a decision expected within the next several months on whether changes need to be made.

Last month, the National Institutes of Health published
a surprising report
in The Lancet showing that circumcision reduced a man's risk of contracting HIV, the AIDS virus, through heterosexual sex by 51 to 60 percent compared with men who were not circumcised. The findings were based on two trials in Africa involving more than 7,500 men and were halted early because the preliminary results were so striking.

Another study
, published in the journal Pediatrics in November, followed 510 New Zealand newborns until age 25 and found that circumcision cut the risk of contracting sexually transmitted diseases by about half.

These studies are just the latest to point to circumcision’s potential health benefits, says AAP president Dr. Jay E. Berkelhamer.

“There have probably been hundreds over the years showing that circumcised males have lower rates of urinary tract infections, penile cancer and a variety of STDs, including HIV,” says Berkelhamer.

Researchers believe that the warm, moist area under the foreskins of uncircumcised men may be a breeding ground for infections, though behavior, lifestyle and cleaning habits — not the foreskin — make the biggest impacts on health.

Drastic measure?
Reiss agrees that it’s true that babies with foreskins do have a higher number of urinary tract infections and possibly other problems, but he says these are usually easily treated with antibiotics. “We don’t cut an eyelid off because we have a sty,” he says.

Furthermore, penile cancer is such a rare disorder that it also does not make sense to surgically remove the foreskin in order to prevent it, says Reiss. He draws a parallel to breast cancer: “We would never routinely give girls mastectomies just so they don’t someday have breast cancer.” And, of course, condoms can help prevent many STDs.

Until a decade ago, Dr. Thomas E. Wiswell, a neonatologist, researcher and professor of pediatrics at the University of Florida in Gainesville, would have sided with Reiss.

“Earlier in my career I was not in favor of circumcision,” he says. “Over the years, though, I changed my position because of the research. The vast majority of M.D.s in our country and even elsewhere will tell you there are health benefits associated with circumcision.” He acknowledges, however, that it’s not an easy decision for parents.

Wiswell contends that the Internet is flooded with inaccurate information about circumcision that he says is aimed at scaring parents instead of presenting health information. He’s calling for more obstetricians, birthing instructors and pediatricians to bring the subject up for discussion and supply parents with both sides of the argument.

“I know that circumcision is controversial and I think the decision should be up to the parents,” says Wiswell. “But I’d like to see them make reasonable choices based on the best science can offer as well as their personal beliefs.”

But Reiss sees the issue as more one-sided: “We’re harming our little boys when we do surgery on their genitals for no reason.” He notes that society is widely appalled at female circumcision but seems to accept blindly that male circumcision is normal.

'Intactivists' unite
Reiss prefers to call males who have not been circumcised “intact.” And he and other “intactivists” don’t believe parents have a right to make the decision to circumcise.

“If it was something that was clearly beneficial such as immunizations, I’d agree that parents have the right to make the decision,” says Reiss, “but God made man with a foreskin for a reason.”

Though this hasn't been scientifically confirmed, Reiss believes that circumcision reduces adult touch sensitivity and sexual pleasure. He says he's heard from plenty of adult men who are regretful and often angry that their parents had them circumcised.

With so much science and emotion on the playing field, whether to circumcise will continue to be a tough call for parents. Berkelhamer says parents should not expect — or even want — their doctors to make the decision for them.

“More and more in health care in general the role of the doctor is to present the information and then allow the patient or, in this case, the patient’s parents, to make the decision,” he says. “I think that’s appropriate.”

Berkelhamer says there are many factors that come into play when parents make their decision. Tradition, religion and philosophical beliefs can weigh heavier than any medical gains.

Barish, a seasoned parent, believes that whatever couples decide for their newborn sons is probably OK.

"Whether a boy is circumcised or not doesn’t matter so much," she says. "He can be healthy, happy and love his penis either way.”

Victoria Clayton is a freelance writer based in California and co-author of "Fearless Pregnancy: Wisdom and Reassurance from a Doctor, a Midwife and a Mom," published by Fair Winds Press.